For discussion and debate about the ethics of health care organizations and the wider health system.

Thursday, October 16, 2008

Market and Rights in the Colombian Health Care System (2)

I wrote my first post about Colombia prior to attending the Colombian Health Economics Association conference. I'm writing this follow-up post in the Bogota airport before my flight back to the U.S.

I was tremendously impressed with the thoughtfulness, openness and warmth of the participants at the conference. There is a growing cadre of well trained health economists and policy experts in Colombia. This all to the good. Colombia is at the edge of a roller coaster ride through the thorniest questions in global health policy. I told my hosts that Colombia may provide a key learning opportunity for other countries the way Oregon did at the inception of the Oregon Health Plan.

With the passage of Law 100 in 1993, Columbia embraced (a) a commitment to achieving universal health insurance coverage and (b) the theory of market competition as the driving force for improvements in quality and cost. It's not quite there with universal access, but insurance coverage is actually at 90%, with the greatest gains being in the informal sector and non-urban populations. The Colombian experience is close to confirming the finding in many other countries (sadly, always excluding the U.S.), that a social insurance approach can achieve universal coverage.

Evidence about the efficacy of managed competition in driving cost and quality improvements is less clear. Insurers have not been competing on price, and the provider community has not been confronted with the kind of incentive for improved efficiency that the theory postulates.

Here's what's especially challenging and exciting about Colombia's situation. As one speaker put it - the Constitutional Court has "thrown a bomb into the health system." The Colombian Constitution creates a "right to health" for citizens. In a what I see as a constructive "bomb," the Court has directed the health ministry to bring about full coverage and equalization of the benefit package between the Contributory Regime and Subsidized Regime (see previous post).

But the Constitutional Court is driving Colombia into new territory in terms of what the "right to health" means in the real world. Here are three major questions Colombia will be grappling with in the next few years:

1. The Court appears to have decreed that the individual physician is the arbiter of what kind of care is necessary to fulfill the right. This is a recipe for near term disaster. Given all we know about unwarranted variations in practice and widespread failure to practice evidence based medicine, it makes no sense to allow each physician to define the contours of what the "right to health" means in terms of health care.

If the law plays out this way I can imagine a suit based on the claim that allowing each and every physician to define "medical necessity" impedes the overall right to health by creating threats to patient safety and depleting the available funds!

2. The Court has focused on access to health care. But we know that health care accounts for a relatively small proportion of population health gains. In the U.S. we see how runaway health care costs diminish health by "stealing" funds from other drivers of health - employment, education, housing and more. Colombia will have to thrash out this dilemma under the spotlight created by the Constitutional Court.

3. The Constitutional Court's ruling appears to imply that withholding potentially beneficial services is inconsistent with the right to health. Perhaps in paradise there is no need for rationing. But on earth rationing is an inevitable necessity in health care. The only question for societies is whether rationing is done fairly, with clinical wisdom, in a way that the population can understand and, over time, accept.

In my presentation at the conference I suggested that the "accountability for reasonableness" framework that Norman Daniels and I have developed (see here) might be useful in sorting out the conflict between the right to health and the reality of rationing. But whatever happens with that suggestion, Colombia will be a hot spot for health system learning in the next few years.

2 comments:

Health standards in Colombia have improved greatly since the 1980s. A 1993 reform transformed the structure of public health care funding by shifting the burden of subsidy from providers to users. As a result, employees have been obligated to pay into health plans to which employers also contribute. Health in Colombia refers to the prevention, treatment, and management of illness and the preservation of mental and physical well being through the services offered by the medical, nursing, and allied health professions in the Republic of Colombia.-------------------------hesslei...........

I'm glad to hear your overall assessment of health standards in Colombia. As I hope I coveyed in my two postings about Colombia, I was very impressed with the energy and thoughtfulness being devoted to the health care reform process that was launched in 1993 and to the implications of the recent Constitutional Court ruling. I hope to be doing further work on the Colombian health system in conjunction with colleagues in Colombia.

About Me

I've been in health care for almost 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

Organizational ethics is what this blog is all about. I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings.